Investigating Electronic Nicotine Delivery Systems (Ends) Use Amongst Telephone Quitline Participants

  

    
Demographics 
    
 
    
ENDS only    User 
    
Dual User 
    
Cigarette    only 
  
  

    
Age*
    
Average Age
    
46.362
    
44.279
    
46.214
  
  

    
Age Grouped*
    
Young Adult (18-30)
    
16.58%
    
20.89%
    
17.22%
  
  

    
Adult (31-45)
    
28.57%
    
12.91%
    
28.13%
  
  

    
Middle adulthood    (46-60)
    
38.04%
    
35.91%
    
38.81%
  
  

    
Older adulthood    (61+)
    
16.81%
    
30.29%
    
15.84%
  
  

    
Sex*
    
Female
    
56.16%
    
65.19%
    
61.60%
  
  

    
Male
    
43.84%
    
34.81%
    
38.40%
  
  

    
N. Coaching    Calls*
    
Average N. Coaching    Calls
    
2.189
    
1.746
    
1.766
  
  

    
Education*
    
High School Degree    or GED
    
24.96%
    
34.11%
    
36.15%
  
  

    
Some College
    
28.93%
    
31.27%
    
28.62%
  
  

    
College Degree
    
22.06%
    
17.55%
    
16.31%
  
  

    
Less than high    school degree
    
10.00%
    
14.59%
    
16.68%
  
  

    
No Response
    
14.05%
    
2.48%
    
2.23%
  
  

    
Trade/Vocational    school
    
0.00%
    
0.01%
    
0.02%
  
  

    
Insurance    Levels*
    
Uninsured
    
31.07%
    
26.43%
    
31.47%
  
  

    
Commercial
    
20.69%
    
19.65%
    
21.06%
  
  

    
Medicaid
    
18.85%
    
22.86%
    
21.49%
  
  

    
Medicare
    
14.66%
    
15.09%
    
14.24%
  
  

    
Other
    
11.07%
    
14.56%
    
10.39%
  
  

    
Don't Know
    
3.66%
    
1.42%
    
1.35%
  
  

    
*Indicates significant difference    between the groups at p<.05.
      
 
  

Table 3:  Comparison of Demographic Characteristics.

The average age of the entire sample was 46.09 years of age, E&Cig participants were the youngest (44.29) average group followed by CigO (46.21) and ECigO (46.36). The differences is average age were statistically significant (df=2,F-Value=170.54, p-value<.0001). With further post hoc analysis using Tukey’s Studentized Range test for the average age it is determined that the mean ages differ between all group combinations except ECigO and CigO.

ECigO participants were more likely to have a college education (22.06%) compared to E&Cig (17.55%) and CigO (16.31%) participants. The percentage of participants in a higher level of education by study group was significant (χ=1029.48, p-value<.0001).

There were also differences in insurance coverage amongst the three study groups. EcigO participants reported being uninsured (31.07%) more than E&Cig (26.43%) but similar to CigO (31.47%). E&Cig participants were most likely to be insured through Medicaid (22.86%) compared to EcigO (18.85%) and CigO (21.49%). When evaluating insurance groups to study population there was a significant difference in the proportions (χ=535.37, p-value<.0001).

Discussion

ENDS products are becoming increasingly prevalent among current combustible tobacco users as well as those who have never used tobacco products [2,3]. Callers to tobacco quitlines provide an opportunity to understand ENDS use patterns in this population. The current study looks at one of the largest U.S. quitline databases to better understand how ENDS users compare to non-ENDS users in demographics and prevalence. These findings will contribute to knowledge about the use patterns of current tobacco users who access tobacco quitlines.

Quitline participants that utilize both ENDS and Cigarette products tend to be similar to cigarette only users, but notable differences arise when reviewing participants that reported ENDS use without cigarette use. ENDS only participants are more likely to be male and have a college education. This unique demographic profile provides insight into how to the ENDS population differs from a quitline perspective and potential barriers in their attempt to quit tobacco products.

E&Cig participants, who are sometimes, consider dual tobacco users, demonstrated time to first use of ENDS later in the day compared with EcigO and CigO. It is important to note that these users did demonstrate time to first cigarette significantly earlier than ENDS, thus potentially speaking to a difference in dependence level between ENDS and combustible products [10,11]. Another potential reason for this difference is that ENDS products physiologically impact the brain differently than combustible products, providing more of a quick hit to nicotinic receptors in the brain [11].

EcigO and E&Cig participants showed no difference in their rationale for ENDS use, indicating the two of the top three reasons as cessation focused (i.e., “quit other tobacco”) or harm reduction (i.e., “cut down on other tobacco”). The reasons endorsed by participants help inform quitline practices to continue to continue to work with participants on cessation and/or harm reduction from all tobacco products because these are their reasons for using these products. It also allows quitline staff to provide participants with information on evidence-based cessation practices that include coaching and quit medication combined. On the other hand, the third reason endorsed by ENDS users (i.e., “For times when the participant cannot smoke or use other tobacco”) highlights a growing fear from the health community. This is the fear that dual use of products will reduce the urgency to quit tobacco products [11], which has ramifications for continued prolonged use which has the potential for long-term health effects [12].

Other data that demonstrates consistency with cessation or harm reduction as primary motivators is how ENDS users engage with a quitline cessation program. These results show that EcigO participants utilize telephone coaching at a significantly higher rate compared to E&Cig and CigO users. This data is consistent with previous studies that found that ENDS users more frequently cite cessation as their primary motivation for using ENDS products [13- 16] which highlights a difference in motivation. This motivation has the potential to impact quitline participants’ progress and potential success in a telephone quitline cessation program. Furthermore, the EcigO group may have been previous dual users who have moved to EcigO prior to entering the quitline program. Since EcigO participants maybe further in their quit attempt compared to E&Cig and CigO participants another possibility for the higher program engagement may be that EcigO users may have a lower dependence level on ENDS products overall compared with more traditional ones.

Limitations

One possible limitation to this study is that there is likely a selection bias with the participants. Due to the fact that participants who enroll and utilize a telephonic quitline program may be very different from those individuals who choose not to call, potentially limiting the generalizability of study findings. For example, the average profile of a quitline participant is female, over 45 years of age and has been utilizing tobacco products for more than ten years.

Conclusion

ENDS use has increased in both the general population and the NJH quitline population, with rates even higher in these tobacco users. Better understanding the needs of tobacco users who use ENDS products is crucial to continued understanding of use patterns overall. The characteristics for this large, multistate sample of quitline callers has important implications for further investigation and informing the broader tobacco community about ENDS use patterns in a quitline population. This data has the potential to inform more targeted and tailored cessation strategies for all ENDS users.

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